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Headache Care

The Difficult Headache Patient

Wednesday, Feb 11 2009

  

In 1978, James E. Groves published his now classic paper “Taking Care of the Hateful Patient.” He described four classes of patients who might strike dread into a physician’s heart but was careful to note that a single patient might encompass more than one of these attributes.

To these four stereotypes, we have added a fifth, called, for lack of a better term, the “day-ruiner.” The day-ruiner usually arrives on the office doorstep, notes in hand, prepared to settle in for a prolonged period of intense discussion. Many of these patients appear to have found special comfort in prepaid organizations such as health maintenance organizations, which allow them to visit the physician’s office frequently without the pain of paying for the interaction. They are characterized by striking adaptiveness and are capable of turning an ordinary 15-minute visit into an hour-long verbal wrestling match. Furthermore, they are often late but insist on being seen nonetheless, and they are frequently married to persons of similar personality. The day-ruiner is best described as demanding, manipulative, tangential, disorganized (or hyperorganized), frustrating, complaining, litigious, disputatious, and cantankerous. These stereotypes are familiar to most practicing physicians. Like other difficult patients, they sometimes engage in games with headache as the primary complaint, hence, the term “headache games.”

A small group of difficult headache patients remains. This is the chronic group, characterized by persisting complaints and resistance to treatment; they are often very difficult to deal with professionally. It is this group that we have characterized and separated into the ten headache games that follow.

Headache Game 1
This is the “You’re my last hope, doctor” game: “None of the other doctors I’ve seen have done me any good. Most of them shouldn’t have licenses. All they’re interested in is money. They order too many tests. But I know you’ll be different, doctor.”

Commentary
Do not fall into this trap. Often, this game is played by the person who accompanies the headache patient. Both parties (e.g., husband and wife or patient and child) may contribute. It is unlikely that all previous physicians seen by the patient have been greedy and incompetent. You can be sure that you are next on the list for this form of doctor-bashing.

Solution
Advise the patient that you are not a magician and no miracles are likely to occur. We tell patients that all physicians use the same medications. If you suspect your patient is litigious, be especially careful about criticizing your colleagues. Be helpful, assertive, and supportive; but maintain distance from these patients.

Headache Game 2
This is the “It’s my diet” game: “I know it’s some food I’m eating. Of course, I’ve given up most foods, and all I eat now are scallions and broccoli with garlic powder. I never touch sugar, and meat is so bad for you. But

I keep having headaches. Could I have some allergy tests?”

Commentary
We generally advise a healthy diet with regular meals and provide guidance regarding this matter. Although diet may be a provoking factor in migraine, it is important to point out that it is only one factor among many. Eating a rigidly restricted diet is unwise. It tends to reinforce obsessive habit patterns.

Solution
Send the patient for professional nutritional help, or have him or her purchase a cookbook for migraine patients. Alternatively, devise dietary guidelines of your own and instruct the patient in their use. Eating should be one of life’s great pleasures. Emphasize that to your patient.

Headache Game 3
This is the “It’s my sinuses” game: “I’ve had my nose fixed and two Caldwell-Lucs and turbinates removed, but I keep having sinus troubles. I can’t breathe through my nose, and the pain at the bridge of my nose is awful. It radiates through my ears and down my back out my tailbone. If only I could get my nose and sinuses straightened out, everything would be fine.”

Commentary
This is an example of obsessive preoccupation with a single organ system. Although chronic sinusitis can produce chronic headache, the diagnosis is usually readily evident. Given today’s modern methods of investigation, there should be no real problem of establishing the diagnosis or excluding it. The pain pattern described here is also bizarre and does not fit anatomic guidelines.

Solution
Once a problem has been thoroughly investigated, one should move on to other etiologies. Discourage dwelling on a single organ system. Change the topic. Do not abet the situation by agreeing to another consultation, another study, or another operation.

Headache Game 4
This is the “It’s my TMJ” game: “And my tongue burns, too. I’ve been to three dentists, had complete caps, my bite has been reworked, and I almost had both TM joints replaced; but at the last minute I decided against that procedure. My teeth and gums burn all the time, and my mouth is so sore I just can’t stand it. Do you think it could be my dental fillings? Should I have another gum biopsy?”

Commentary
Unless you are doubly trained in dentistry, our advice is to deflect questions about temporomandibular joint (TMJ) disease to the dental profession. If patients come to us and say their problem is TMJ, we tell them immediately that they have been referred incorrectly and try to refer them appropriately.

Solution
Our test for TMJ disease is to have the patient open and close the mouth repeatedly. If there is no pain and the mouth capacity is adequate, we look elsewhere for a headache etiology. Magnetic resonance imaging of the TMJ may show degenerative changes, but that is true of almost every joint in the body as one ages. Conservative treatment of this problem is best. Try not to contribute to what may be an oral fixation, often a problem in these patients.

Headache Game 5
This is the “I need Demerol” game: “Now look, doctor, let’s get one thing straight. I don’t respond to anything but Demerol (or Percodan). I’m allergic to everything else or it doesn’t work, so don’t give me any nonsteroidal anti-inflammatory drugs, antidepressants, anxiolytics, etc.; and furthermore, I’m resistant to Demerol, so I need big doses, like 200 mg, and maybe repeated once or twice. And I’m not an addict, I know my body.”

Commentary
This patient is seeking drugs. Requests for a specific narcotic, a specific dose, should always arouse suspicion. However, addiction implies daily use, with increasing doses to achieve the same effect. Appearing at an emergency room once every several months for an injection is not addiction.

Solution
Other drugs can be employed in this situation and are, in fact, more effective. Both sumatriptan and dihydroergotamine (DHE-45) can be used. If Demerol or another narcotic relieves your patient, it can be employed provided such use does not become a habit. You can always just say no.

Headache Game 6
This is the “Everything is wonderful in my life” game: “I have such terrible headaches and I don’t know why. My husband/wife is so understanding, what a saint. My son is Phi Beta Kappa at Harvard, and my daughter just won three gold medals at the Olympics. We live in a beautiful house with plenty of money and I love my Jaguar convertible. And of course we travel constantly, always first class, staying at the best hotels, in season. Do you suppose if something was wrong I’d feel better?”

Commentary
This is the Pollyanna syndrome. Nobody has a perfect life, marriage, or relationship with a spouse and children. Patients like this need to learn that it is normal to have some problems that are difficult to resolve, and they do well in self-help group sessions where they can learn to vocalize deficiencies and gain support from group dynamics.

Solution
These patients are generally more easily managed than some of the other game players. A behavioral consultation may be helpful. Often, biofeedback is useful in this situation. Work with the patient with regular visits and reassurance.

Headache Game 7
This is the “I need alternative medicine” game: “All the doctors keep giving me are tranquilizers and pills. I know it’s a hidden infection. I had food allergy testing and turned up positive to Candida. I’m on an anti-Candida diet, and it isn’t easy but I’m sticking to it. I haven’t seen any improvement yet, but I know I’m on the right track. I’d like your opinion, doctor, about Candida, and do you believe in homeopathy, chelation, and acupressure?”

Commentary
If patients wish to pursue alternatives to mainstream medicine, we do not raise objections. It is important, however, not to put your personal imprimatur on these projects, especially if they turn out to be expensive and unsuccessful. Be honest and give your opinion without becoming overbearing, angry, and dictatorial. Remember, you are not the patient’s parent or caretaker, and you are not responsible for another’s behavior.

Solution
Always guide your patient in the directions you believe are appropriate. Be specific in your recommendations, rather than providing alternatives and telling the patient “It’s your choice.” That is the essence of a professional opinion. Try not to become offended if your advice is not followed. A little humility is helpful. None of us has all the answers.

Headache Game 8
This is the “I’m allergic to everything” game: “I’ve been so weak and fatigued, and the headaches, my God, my head feels like it’s splitting with water rushing out and my scalp is on fire and it hurts when I blink. But I found out I’m allergic to light, sound, smell, and touch; and so I’m moving to a colony in the high desert where there’s no smog or odors or perfumes, where the air and water are clean and pure, and I’m going to grow everything organically and Live like people are supposed to live. I’ll show organized medicine. I’ll make it all the way back, then I’m going to write a book and be on the Oprah show.”

Commentary
Make sure that patients such as this are worked up to rule out endocrine disease, myasthenia, and the like. If that has been done, advise the patient that no disease has been found, and that allergy is not a cause of chronic fatigue. If the patient persists and begins to quote from those who lead the clinical ecology movement, advise that chronic fatigue has been a problem for every generation and was called “the vapors” or neurasthenia or effort syndrome in past years.

Solution
Treat the patient’s opinion with courtesy and respect, but do not agree with him or her, especially if you believe that the proposed solution is not correct professionally. Suggest that the patient transfer to the care of another physician with a different outlook. Be honest but firm, and do not argue with the patient.

Headache Game 9
This is the “I need another test” game: “I’m sure there’s something the matter, but the doctors can’t find it. I’ve had three CAT scans, three MRIs, a TCI, an LP, and a bone scan, and it’s all negative. Have you heard of the magnetoencephalograph? Should I have one of those? I’m going to keep going till I find an answer and I don’t care how much it costs Medicare! They owe me. I worked hard for 40 years and always paid my taxes. By the way, do you accept assignment?”

Commentary
This patient is hypochondriacal and believes that a disease is present, despite overwhelming evidence to the contrary. If you follow the patient long enough, of course, the patient will be correct. We are all mortal, and sooner or later a discoverable disease will appear. Furthermore, if patients are covered by third-party insurance or by government funding, the cost of studies is not felt by them, which compounds the problem.

Solution
With newer tests of neurologic function, you may be able to convince these patients that no serious disease is present, particularly by going over the films with them. If this fails and further work-up is demanded, then stand your ground. Although there are no rewards for denying studies, it is still the honorable thing to do if you believe a study is not indicated.

Headache Game 10
This is the “impossible situation” game: “Hey, man, it’s two o’clock in the morning and I’m having a terrible headache. I’ve been barfing since supper. I need a shot, but I don’t have any medicine or syringes or needles. Could you call something in to a pharmacy? I don’t want to go to an emergency room, either; it costs too much. And I don’t know of any pharmacy that’s open, and I don’t have their telephone number either. I’d sure like some help. Do you have any suggestions? And by the way, before you order anything I need to remind you, in case you have forgotten, that I’m allergic to most medications. What if what you are going to give me doesn’t work?”

Commentary
There are impossible situations in medicine, and this is one of them. The patient knows it full well. If, by some miracle, you could relieve all of these complaints, would the patient be happier? Probably not. It is especially disheartening when one hears the last sentence above because the patient, or an enabler, begins to question your plan of treatment before it is even undertaken. Negative thinking of this type is always counterproductive.

Solution
Deferred.

Editors: Silberstein, Stephen D.; Lipton, Richard B.; Dalessio, Donald J.
References
Edmeads, J. (1988). Emergency management of headache. Headache 28:675-679.
Groves, I.E. (1978). Taking care of the hateful patient. N. Eng. J. Med. 298:883-887.
Headache Classification Committee of the International Headache Society. (1988). Classification and diagnostic criteria for headache disorders, cranial neuralgia, and facial pain. Cephalalgia 8:1-96.
Silberstein, S.D. (1992). Evaluation and emergency treatment of headache. Headache 32:396-407.
Silberstein, S.D. and M.M. Silberstein. (1990). New concepts in the pathogenesis of headache. Part II. Pain Manage. 3:334-342. 

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